Improving Surgeon-Patient Communication About High-Risk Surgery

Betty R. Ferrell, PhD, RN


June 06, 2017

Best Case/Worst Case Communication

This novel project targets an important yet difficult clinical scenario: counseling patients facing high-risk surgery. To improve surgeon-patient communication in these situations, Kruser and colleagues[1] developed a training program based on a "best case/worst case" (BC/WC) communication tool.

The 2-hour training was followed by individual coaching and application to both standardized patients and actual hospitalized patients. Interactions were audio-recorded, and additional evaluation data were obtained from the surgeons and follow-up interviews with patient and families.

The BC/WC tool is designed with many practical features, including a simple pen-and-paper graphic depicting treatment choices, and the use of narrative in which, for each option, the surgeon tells a story of what could happen. For example, the choices might be having a complex surgery that would require an intensive care unit stay with tracheostomy and ventilator support versus admission to the palliative care service and supportive care only.

The article provides several of the case scenarios used in training, including an 87-year-old woman with chronic kidney disease presenting with an abdominal aortic aneurysm and an 83-year-old with multiple comorbid conditions and a history of stroke, pulmonary embolism, and coronary artery bypass now presenting with bowel obstruction.

The data analysis for this project had both quantitative and qualitative components. The authors created a fidelity checklist that was used to rate the surgeon's conversations with patients. Follow-up evaluations were conducted with the trained surgeons to assess their continued use of the BC/WC tool. Most important, the researchers conducted follow-up interviews with patients and families between 30 and 120 days after the treatment decisions to gain their input.

The researchers concluded that the study findings support use of the BC/WC tool with patients and families who are facing high-risk surgery.


The literature related to communication in serious illness has increased significantly, but most of the focus has been on palliative care teams and patients with chronic medical conditions. This project is innovative in applying a unique tool—the BC/WC communication guide—to both a training environment (with standardized patients) and actual clinical practice.

The BC/WC teaching intervention is impressive and captures the complexity of care, ethical challenges, and the true importance of treatment decisions for these patients. Moreover, the training and its evaluation were thorough. The authors selected a vulnerable group of frail older patients who were facing high-risk surgery. They focused on "in-the-moment" treatment decisions, recognizing that surgeons, patients, and families often face acute situations requiring rapid decisions.

The authors did a commendable job of honestly describing the challenges of this project, including the difficulty in scheduling training for busy surgeons, the variability often seen in clinical practice, and the intensity of resources required for training. Overall, the article represents very thoughtful, important, and novel work in a understudied area. The decisions and outcomes of complex surgery for frail elders is a major healthcare concern, and this project is a model of palliative care training that has potential for widespread application.


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